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Inquest Conclusions

Date of inquest Date inquest concluded Name of deceased Conclusion
20/09/2017 04/10/2017 MAZUREK, Marcin Miroslaw Marcin Mazurek moved to the segregation unit at his own request following allegations of threats and bullying. During that time there was an incident of deliberate self-harm. An ACCT document was opened. A lack of effective intervention, failure to explore alternative support options other than segregation, led to Mr Mazurek spending an inappropriate length of confinement in segregation (51 days). A lack of adherence to the ACCT requirements meant insufficient involvement and intervention of Mental Health professionals. There was inadequate reporting and recording by both discipline and medical teams, leading to an omission of multi-disciplinary working and communication. Ultimately, there was a lack of holistic overview of Mr Mazurek's concerns and a systemic failure to meet his needs. All of these factors probably contributed to Mr Mazurek's death.
04/10/2017 04/10/2017 BENNETT, Lee Misadventure
04/10/2017 04/10/2017 ROACH, Steven Suicide
04/10/2017 04/10/2017 STARKIE, Phillip Alcohol related
04/10/2017 04/10/2017 TOMLINSON, Alexander Mr Tomlinson died as a result of natural causes, on a background of cardiac changes brought about by drug experimentation.
11/10/2017 11/10/2017 CLIFFORD, Patrick Mr Clifford fell backwards following a faint in the toilet on Ward B4 at the Royal Blackburn Hospital on the 19th March 2016. He suffered a fractured acetabulum as a result. This was treated conservatively. His condition deteriorated over time. He developed pneumonia due to immobility and heart failure and passed away on the 18th September 2016 at Springhill care home in Accrington.
11/10/2017 11/10/2017 CONNOR, Michael Drug related death
11/10/2017 12/10/2017 HYLAND, Anthony Natural causes
11/10/2017 11/10/2017 LYNAS, Melvyn Stuart Suicide
11/10/2017 11/10/2017 WOOD, Sean James Sean James Wood died on 5 May 2017 on Chancery Road, Chorley due to self inflicted suspension however there is insufficient evidence to find that he intended to end his own life.
12/10/2017 12/10/2017 CURWEN, Marion Mary Accidental death
12/10/2017 12/10/2017 DICKINSON, Glynn Barry Suicide
12/10/2017 12/10/2017 MONTGOMERY, Raymond Joseph Accidental death
12/10/2017 12/10/2017 WHELAN, Rose Nancy Jane Misadventure
17/10/2017 17/10/2017 RICHARDSON, Stuart Natural causes
17/10/2017 18/10/2017 SINGH, Avtar Natural causes
18/10/2017 18/10/2017 BOLTON, Gary Accidental death
18/10/2017 18/10/2017 GREEN, Shane Ian Natural cause
18/10/2017 18/10/2017 McCORDKINDALE, Tamara Skye Accidental death
18/10/2017 18/10/2017 SHERLOCK, Frederick Graham Industrial disease
02/11/2017 18/10/2017 WATSON, Derek Suicide
This is the only information that can be provided at this time.